cdi college author contact information email: … farnese cas… · objective: the purpose of this...

Running head: EFFECTS OF MYOFASCIAL RELEASE AND MUSCLE ENERGY TECHNIQUES ON A PATIENT WITH IDIOPATHIC SCOLIOSIS

The Effects of Myofascial Release and Muscle Energy Techniques on a Patient with Adult

Idiopathic Structural Scoliosis: A Case Study

Sherry Farnese

CDI College

Author Contact Information

Email: [email protected]

Phone: (604) 657-3823

Address: #18- 19525 73 Ave, Surrey, BC, V4N 6L7

mailto:[email protected]

EFFECTS OF MYOFASCIAL RELEASE AND MUSCLE ENERGY TECHNIQUES ON A PATIENT WITH IDIOPATHIC SCOLIOSIS

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Table of Contents

Abstract ...........................................................................................................................................3

Keywords………………………………………………………………………………….4

Introduction ....................................................................................................................................5

Scoliosis…………………………………………………………………………………...5

Myofascial Release and Muscle Energy Techniques……………………………………...6

Methods ...........................................................................................................................................7

Patient Profile.......................................................................................................................7

Physical Examination...........................................................................................................9

Summary of Treatments………………………………………………………………….10

Results…………………………………………………………………………………………...11

Table 1. Costovertebral Expansion………………………………………………………11

Table 2. Thoracic Spine Rotation………………………………………………………. 12

Table 3. Thoracic Spine Flexion…………………………………………………………12

Table 4. Apley’s Scratch Test……………………………………………………………13

Table 5. Quadruple Visual Analogue Scale……………………………………………...13

Table 6. Symptom Diagram……………………………………………………………...14

Table 7. Headaches………………………………………………………………………14

Table 8. Special Tests……………………………………………………………………15

Figure 1. Anterior View………………………………………………………………….16

Figure 2. Posterior View…………………………………………………………………17

Figure 3. Apley’s Scratch Test…………………………………………………………...18

Figure 4. Thoracic Spine Rotation……………………………………………………….18

Figure 5. Scapular Level…………………………………………………………………19

Discussion/Conclusion………………………………………………………………………….20

References……………………………………………………………………………………….24

Appendix………………………………………………………………………………………...27


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Abstract Objective: The purpose of this case study is to determine if Myofascial Release (MFR) and

Muscle Energy Techniques (MET) will increase spinal range of motion, improve chest

expansion, decrease muscle tone imbalances, improve posture, and decrease pain symptoms

associated with structural scoliosis in a 21-year-old female case subject.

Background: Studies have shown that manual therapy can improve spinal range of motion

(ROM) and pulmonary function, correct postural imbalances, and decrease pain symptoms in

subjects with scoliosis. The aim of this study is to treat the postural dysfunctions and symptoms

associated with scoliosis by targeting the shortened hypertonic musculature and correcting axial

spine restrictions.

Methods: A 21-year-old female participated in 10 treatments for 60 minutes consisting of 1

session a week over a period of 10 weeks. MFR was used to address muscle imbalances and treat

shortened musculature typical of a right thoracic, left lumbar S scoliosis curve. MET was used to

correct any imbalances in the spine, ribs, pelvis, and sacrum. Assessments performed included

postural observation with photos, thoracic range of motion measurements with a tape measure

and goniometer, costovertebral expansion, special tests, Quadruple Visual Analog Scale

(QVAS), Symptom Diagram, and Oswestry Low Back Questionnaire.

Results: Thoracic spine flexion, right thoracic rotation, and rib expansion increased significantly

for the subject. Before and after photos show postural changes, which are most noticeable in

shoulder levels and the scapular region. The Quadruple Visual Analog Scale (QVAS) reported

pain levels went from a 4/10 to 1/10. The Symptom diagram initially showed 14 areas of pain

which was reduced to 3 areas. The participant experienced a gradual decrease in headaches,

going from daily headaches prior to treatment to no headaches in the final week.


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Conclusion: MFR and MET were effective at increasing spinal range of motion and chest

expansion, improving posture, and decreasing pain symptoms exhibited by a female subject with

structural scoliosis. However, further investigation is needed with a larger sample size, longer

time frames, and the use of pre and post x-rays.

Keywords: Scoliosis, Massage Therapy, Myofascial Release, Muscle Energy Techniques,

MET, Neuromuscular Technique, Thoracic Range of Motion, Chest Expansion, Costovertebral

Expansion


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Introduction

Scoliosis

Scoliosis is a disorder of the spine characterized by a lateral deviation of the spinal

column beyond 10 degrees and by rotation of the vertebrae. Spinal curvatures have been found in

medical literature as far back as ancient Greece where Hippocrates developed treatment

protocols to correct spinal deformities (15). Scoliosis can be classified in many ways including

the age of onset, whether it is structural or functional, the location of the curve, and the etiology

(1,2). Idiopathic scoliosis is diagnosed when there are no clear clinical findings for the cause.

Idiopathic scoliosis is the most common form of structural scoliosis occurring in 2-3% of

the population, and idiopathic scoliosis accounts for 75% to 85% of all cases (1,3). Idiopathic

scoliosis is divided into 3 groups: infantile, juvenile, and adolescent depending on when the

curve is diagnosed. Adult scoliosis can either be a further progression of adolescent scoliosis, or

a result of degenerative changes or trauma (4,1). The etiology of idiopathic scoliosis is not clear,

but it is thought to have a genetic link. Some other possible causes are neuropathy, myopathy,

degenerative changes, and trauma (1,3). Girls are 6 times more likely to have scoliosis than boys.

If the spinal curve is greater than 30 degrees, the ratio rises to 10 girls to 1 boy (4).

Symptoms and other health related conditions are widely dependent on the age of the

patient, the location of the curve, and the severity. Some common symptoms are pain, nerve root

and joint irritation, decreased or altered range of motion, and a decrease in the patient’s quality

of life (3,4,5). Patients often present with a humped rib cage and cosmetic deformities which can

lead to poor self-esteem and psychosocial problems (4). Advanced rotational deformities can

impair chest expansion resulting in abnormal respiratory function and cardiopulmonary problems


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(5). There is a higher risk of complications for people who have been diagnosed before puberty

with moderate to severe scoliosis because of the curve progression (1).

Scoliosis treatment depends on the degree of the curve and the age of the patient. A curve

that is less than 20 degrees is usually monitored and treated with physiotherapy. Bracing is

usually recommended for curves between 30 and 45 degrees in adolescent idiopathic scoliosis.

Surgical correction or the insertion of Harrington rods is often recommended when the curve

exceeds 45 degrees (4,6). Physical therapy and exercise are highly recommended for those with

scoliosis, but there is a lack of research and evidence on how effective it is at preventing

progression (6,7).

Myofascial Release and Muscle Energy Techniques

The first known use of Myofascial Release was in the 1940s, but it wasn’t until 1981 an

Osteopathic Physician labeled the term myofascial release (10). Myofascial Release is a manual

massage therapy technique that uses gentle sustained pressure to release fascial adhesions (8).

These fascial adhesions impact muscle function, create decreased ROM, and distorted

neuromuscular input (19). Fascial restrictions can develop from many things such as trauma,

surgery, lack of blood flow, injury, structural dysfunction, overuse, and poor posture. These soft

tissue restrictions put stress on the body resulting in dysfunction, pain, and decreased mobility

(9,10). According to a Systemic Review on Myofascial Release as a Treatment for Orthopedic

Conditions in 2013, “Fascia is believed to be 1 continuous piece of tissue working in connected

“chains” to create tensegrity in the body. Therefore, when fascia in one area is stretched, it can

cause tightness, restriction, and pain in another part of the body (10).” MFR works by increasing

blood flow and activating the stretch reflex in muscles (8,9).


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Muscle Energy Technique is an osteopathic technique developed in 1988 that uses the

energy of a contracting muscle to help restore normal function to the muscles and spinal joints

(8). Restricted joints can cause muscle imbalances, spasms, pain, and reduced or dysfunctional

range of motion (11,12). Neuromuscular techniques produce a stretch on the tendon that

stimulate the Golgi tendon organs which inhibit muscle tension (12). Although there is very

limited research regarding the effectiveness of MET, studies have reported decreased pain,

reduced muscle tension and spasm, increased range of motion, and improved strength with MET

(11,13,14).

Scoliosis causes soft tissue and bony dysfunctions which can create muscle imbalances,

fascial restrictions, spinal deformity, joint restrictions, impaired range of motion, decreased

pulmonary function, and pain (4). The muscles surrounding the spine greatly affect its shape and

movement (19). The use of MFR can reduce myofascial restrictions which helps to decrease

muscle tone imbalance, increase spinal range of motion, and increase chest expansion (8,9,10).

MET can be used to normalize dysfunctional joints of the spine to decrease muscular

asymmetries, improve posture and spinal range of motion, and decrease pain caused by scoliosis

(11,12,13,14). This case study will focus on the use of these techniques on a female subject with

adult idiopathic structural scoliosis. The expected outcomes for this case study was to increase

spinal range of motion, improve chest expansion, decrease muscle tone imbalances, improve

posture, and decrease pain symptoms.

Methods

Patient Profile

The patient is a 21-year-old female that is currently a full-time student and a part-time

waitress. As a student, the subject sits for long periods of time studying which she contributes


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pain symptoms. She works as a server 2 days a week, and she notices pain in her mid-back when

she holds serving trays. She describes her physical level as moderately active because she plays

soccer 4 times a week. During soccer the subject doesn’t feel pain symptoms, but after she feels

pain in her left shoulder. She sprained her right ankle in soccer 5 days prior to the first treatment

and had mild swelling and bruising, but she can fully weight bare on it. The patient has played

competitive soccer since she was five years old and reports that she has sprained both ankles

multiple times. Furthermore, the patient experiences stress from school, which she says can

affect her sleep by keeping her up all night.

The patient discovered she had scoliosis about a year ago during a massage which was

confirmed by x-rays in February 2018 (Appendix 11). She was diagnosed with adult idiopathic

structural scoliosis with a right thoracic curve of 28 degrees and a left lumbar curve of 19

degrees. The patient is young and active, and she says she does not have any physical limitations.

The structural asymmetries of the rib humping and elevated right shoulder bother her and make

her self-conscious. The patient complains of a dull aching pain on her right side in her chest, ribs,

erectors, rhomboids, left quadratus lumborum and bilateral shoulder pain. She says she usually

experiences mild daily headaches when she is studying for extended periods of time. The pain

has been infrequent for over a year but has been gradually getting worse. The subject is not

seeing any other practitioners and has not had any treatment for her scoliosis. She claims that

using heat and stretching helps with the pain.

The tools of assessment used were a health intake, postural exam, joint exams, and

special tests. Photos were taken before the initial treatment and after the last treatment.

Costovertebral expansion and thoracic range of motion measurements with a tape measure and

goniometer were taken on the first, fifth, and tenth visits. Each visit the patient filled out a QVAS


9

and a Symptom Diagram (Appendix 1,2). The Oswestry Low Back Questionnaire was done the

first and last treatment (Appendix 4).

Physical Examination

Baseline measurements and photos were taken by a postural exam with four positions:

anterior, posterior, and two lateral views (3). Postural faults were noted using landmarks to make

the observations more consistent. The patients left shoulder was significantly lower than her right

shoulder and her right iliac crest was lower than her left. Typically with a right S curve of the

spine the left shoulder and left hip appear lower than the right, so there is a slight deviation from

the standard basis (8). The right shoulder appeared to be more anterior and the left shoulder was

rotated more internally. The right thoracic and left lumbar curve were apparent with noticeable

scapular and rib abnormalities.

Palpation revealed that the right anterior superior iliac spine was more inferior than the

left, and the right posterior superior iliac spine was more superior than the left. This indicates

possible anterior rotation of the right ilium. Hypertoned and tender muscles palpated were the

right trapezius, levator scapula, scalene, sternocleidomastoid, pectoral muscles, quadratus

lumborum and lumbar erectors. On the left half of the body hypertonicity of the latissimus dorsi,

mid-trapezius, thoracic erector spinae, intercostals, and quadratus lumborum were noted. These

findings were consistent with the presentation of a scoliotic S curve (8).

Joint exams were performed for the glenohumeral (GH) joint and thoracic spine. ROM

appeared normal for the GH joint with pain on internal rotation. Thoracic range of motion was

limited in rotation to the right, and the subject experienced pain in flexion and extension.

Thoracic spine rotation measurements were taken with a goniometer following a 2012 study on

the Reliability of Thoracic Spine Rotation Range of Motion Measurements in Healthy Adults


10

(18). Thoracic spine flexion was taken with a measuring tape starting at the spinous process of

C7 to T12 while standing. The patient flexes forward and the distance is measured between the

same spinous processes (3). Costovertebral expansion measurements were taken at three

different levels to determine chest expansion (3).

The Skyline test was used to check for functional or structural scoliosis and was positive

for structural scoliosis (3). The asymmetries found in the ilium and scapular areas warranted

further special tests to determine other contributing factors to the scoliosis dysfunction, which

are shown in Table 8. Apley’s Scratch test was performed and noted with a measuring tape (3).

Summary of Treatments

This case study included a total of 10 treatments once a week for 10 weeks, which all

followed the same protocol. Each treatment was 60 minutes with 35 minutes in prone, 20

minutes in supine, and 5 minutes side lying. The patient exhibited muscle imbalances that are

common with a right S thoracic curve. With an S thoracic scoliotic curve the convex thoracic

right side is typically stretched and weak, while the left thoracic concave side musculature is

typically hypertoned (9). The muscle imbalance over time can create bony deformities because

the bone will remodel itself along lines of stress and tension (16).

The treatment started in prone with MFR consisting of a sustained compression that was

held for 2-3 minutes into the myofascial restriction, while taking up tissue slack, until a release

was felt (9). A pain scale of 1-5 was used to stay within the patient’s pain tolerance (Appendix

3). Working superficially to deep releasing the left middle and lower trapezius, rhomboids,

latissimus dorsi, serratus anterior, thoracic erector spinae, intercostals, and quadratus lumborum.

The right trapezius, levator scapula, quadratus lumborum and lumbar erectors were also treated

in prone. MET was performed to the sacrum for left central sacral torsion (Appendix 9) and to


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the ribs 4 to 10 on the right convex side (Appendix 10). In supine the right sternocleidomastoid,

scalenes, pectoralis major and minor were treated with MFR. MET was performed to the right

first and second rib (Appendix 10). The right anterior rotation of the ASIS was corrected with

MET as well as distraction of the sacroiliac joint (Appendix 7,8). In the side lying position MET

was done bilaterally on the QL with more focus on the left side (Appendix 6). The decreased

right thoracic rotation was addressed seated at the end of the treatment using a rotational MET

technique (Appendix 5).

Results

Table 1 shows chest expansion which is measured at the axilla, xiphoid, and 10th rib all

improved in expansion. The 1st Tx measurement for the 10th rib was 0 cm.

Table 1. Costovertebral Expansion measured in centimeters.

1st Tx 5th Tx 10th TxAxilla 2 3.75 4Xiphoid 2.1 2.8 510th Rib 0.03 2 2.5

0

1

2

3

4

5

6

Cost

over

tebr

al E

xpan

sion

(cm

)

Treatment Session #

Costovertebral Expansion


12

Table 2 shows thoracic spine rotation, which improves on the right side throughout the

treatments ending with almost equal left and right rotation.

Table 2. Thoracic spine rotation measured in degrees.

Thoracic spine flexion is shown in table 3.

Table 3. Thoracic spine flexion measured in centimeters.

1st Tx 5th Tx 10th TxLeft 49 50 52Right 36 43 50

0

10

20

30

40

50

60

Goni

omet

er R

otat

ion

Mea

sure

men

t(D

egre

es)

Treatment Session #

Thoracic Spine Rotation

1st Tx 5th Tx 10th TxThoraic Spine Flexion 0.1 1 3.2

0

0.5

1

1.5

2

2.5

3

3.5

Thor

acic

Spi

ne F

lexi

on (c

m)

Treatment Session #

Thoraic Spine Flexion


13

Table 4 shows the results of Apley’s Scratch test.

Table 4. Apley’s Scratch test measured in centimeters from the middle fingers.

Table 5 shows the QVAS which was taken before each treatment. There was a decrease

in overall back pain, the patient’s typical average pain, and their pain at its worst.

Table 5. Quadruple Visual Analogue Scale

1st Tx 5th Tx 10th TxRight 9 7 6.5Left 10.5 9 7

0

2

4

6

8

10

12

Dist

ance

bet

wee

n M

iddl

e Fi

nger

s (cm

)

Treatment Session #

Apley's Scratch Test

Tx 1 Tx 2 Tx 3 Tx 4 Tx 5 Tx 6 Tx 7 Tx 8 Tx 9 Tx 10Pain right now 4 4 6 3 5 2 1 3 3 1Typical average pain 4 4 4 4 4 4 2 1 1 2Pain at its worst 7 7 8 7 7 7 7 7 6 5

0123456789

Leve

l of P

ain

on a

Ten

-Poi

nt S

cale

Treatment Session #

Quadruple Visual Analogue Scale- Back Pain


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Table 6 shows the Symptom diagram which was taken before each treatment.

Table 6. Symptom Diagram

Starting the treatments, the patient experienced headaches every day and at the last 2

treatments the subject reported having no headaches as seen in table 7.

Table 7. Number of headaches per week.

Tx 1 Tx 2 Tx 3 Tx 4 Tx 5 Tx 6 Tx 7 Tx 8 Tx 9 Tx 10Areas of Pain 14 11 12 9 11 7 7 5 4 3

0

2

4

6

8

10

12

14

16

Num

ber o

f Are

as in

Pai

n

Treatment Session #

Symptom Diagram

Tx 1 Tx 2 Tx 3 Tx 4 Tx 5 Tx 6 Tx 7 Tx 8 Tx 9 Tx 10# of Headaches per week 7 7 6 3 3 1 1 2 0 0

0

1

2

3

4

5

6

7

8

# of

Hea

dach

es P

er W

eek

Treatment Session #

Headaches


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The patient completed the Oswestry Low Back Disability Questionnaire (OLBDQ) for

back pain on the first and final visit. On the initial visit the results were a 12% disability and the

final visit showed a 4% disability.

Table 8 shows the results and indications of each of the special tests performed. Special

tests can be found in Orthopedic Physical Assessment (3).

Special Test Initial Assessment Results Final Assessment Results

Skyline + Structural scoliosis + Structural scoliosis

Gillet’s + Right hypomobile SI joint Negative

Rectus Femoris Contracture

+ Bilateral- Minimal + Bilateral- Minimal

Seated Flexion + Right= left central torsion of sacrum

+Right= left central torsion of sacrum- minimal difference

Pectoralis Major Length + Right hypertoned pectoralis major

Negative

Supine to Sit Inconclusive as to an anterior or posterior pelvic rotation

Negative

True Leg Length Negative- No indication of leg length discrepancy

N/A

Thomas Negative- No indication of hip flexor contraction

N/A

90/90 Straight Leg Raising

Negative- No indication of hypertoned hamstrings

N/A

Faber Negative- No indication of hip joint involvement or iliopsoas spasm

N/A

Ober’s Negative- No indication of iliotibial band contracture

N/A

H&I Stability Negative- No indication of muscle spasm or instability in the lumbar spine

N/A

Table 8: Special Tests


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The before and after photo in figure 1 shows a significant improvement in the shoulder

levels. The left shoulder and arm appear more symmetrical to the right side.

Figure 1.

Before

After


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In figure 2 there is a dramatic improvement in the scapular region. Before photos show

the left shoulder is lower than the right and the left hip is higher than the right hip. The after

photos show the improvement in posture and muscle balance.

Figure 2.

Before After


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Before and after photos of Apley’s Scratch test show improved GH and scapular mobility

in figure 3.

Figure 3.

Figure 4 shows the before and after photos of rotation to the right.

Figure 4.

Before After

Before After

After Before


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Marks were placed on the subject’s spinous processes at C7, T3, T6, T9, and T12 in

figure 5. There is a visible change in scapular and thoracic region.

Figure 5.

Before After


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Discussion/Conclusion

As hypothesized MFR and MET were able to increase spinal range of motion, improve

chest expansion, decrease muscle tone imbalances, improve posture, and decrease pain

symptoms associated with idiopathic structural scoliosis in a 21-year-old female case subject.

Chest expansion increased gradually throughout the treatments indicating greater rib mobility

and reduced restrictions. These findings also correlate with a 2015 study where thoracic region

self-mobilization was found to increase chest expansion and breathing (17). There was no

movement in the thoracic spine during flexion initially. The patient’s flexion was coming from

her pelvis. On completion of the final visit, flexion in the thoracic spine was within normal range

according to the thoracic measurement test (3). Thoracic spine rotation increased significantly on

the right convex side which could be a result of resetting neuromuscular feedback from MET and

MFR (7,11,19); moreover, reducing the fascial restrictions on the patients left side would also

aid in easier rotation to the right (9,19).

During the GH joint exam there was no noticeable restrictions. The Apley’s Scratch test

assesses combined GH ROM which could be related to scapular restrictions. There was a

noticeable increase from start to finish in ROM as seen in figure 3, which I would attribute to

decreased periscapular and pectoral myofascial adhesions. The Pectoralis Major length test on

the right went from positive to negative indicating reduced hypertonicity and improved mobility.

A systemic review done by C. Mauntel et al. in 2014 concluded: “The findings of this study

indicate that myofascial release therapies are effective in restoring and increasing ROM, without

having a detrimental effect on muscular activity or performance (19).”

The Gillet’s test was initially positive on the right indicating a hypomobile SI joint. The

use of MET on the right to reduce an anterior rotation of the innominate bone at the SI joint and


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the distraction of the SI joints (Appendix 7,8) helped mobilize the stuck SI joint improving

mobility and helping reduce the anterior rotation. The left central sacral torsion, when the sacrum

is rotated towards the left on a central axis making the sacrum more posterior on the left, was

treated with MET (Appendix 9). There was only a slight left torsion on the final assessment.

The decrease in muscle tone imbalance and improved posture is shown in the before and

after photos in figures 1, 2, and 5. The before photos show asymmetries in the shoulders, arms,

scapular region, and hips. Post treatment the body appears more symmetrical and balanced. The

combination of MFR and MET helped decrease areas of hypertonicity and reset the

neurofeedback of the muscular tissue helping restore normal function (19). There is a noticeable

improvement in scapular and GH function shown in figure 4. This illustrates how myofascial

restrictions can limit ROM and joint mobility (19). The marks placed on the spinous processes in

figure 5 appear to show a small decrease in the curve, but that would need to be confirmed with

x-rays. Figure 5 also shows a significant difference in the inferior angles of the scapula. I cannot

say if the scoliotic curve decreased as there are no post x-rays, but there is some evidence that

cobb angles can be decreased through manual therapy according to a study done in 2009 and

2016 (21,22).

The QVAS revealed a decrease in pain symptoms with some fluctuations throughout the

treatment. Some of the increased pain was attributed to her menstrual cycle and increased stress

with school. The symptom picture diagram showed a decrease in the number of areas of pain but

what was most interesting about it was how the areas changed. The shifting locations of pain

could indicate the body rebalancing and adapting to the release of restrictions. Prior to the

treatment, the patient reported having daily headaches, and by the 9th visit she said they were

gone. Decreasing the hypertoned muscles and myofascial adhesions in her upper trapezius,


22

levator scapula, and SCM most likely helped to decrease the number of headaches the patient

experienced. A study done in 2011 found that there was evidence that MFR is effective at

reducing headache frequency (20).

The patient exhibited only 12% disability initially on the OLBDQ, and there was a

decrease on her final treatment to 4%. Because the patient is young and active her scoliosis has

yet to interfere too much with her daily activities. The couple areas of improvement reported

from the OLBDQ were that her pain fluctuates but is overall improving, she can now stand as

long as she wants without extra pain, and she can lift heavy objects without extra pain. The

physical appearance of the subjects back and shoulders did make her self-conscious. She was

very happy with the final results and felt much better about her appearance. After her final

treatment she said that her back and hips felt good and that she doesn’t have pain anymore after

exercising. She also stated that she hadn’t noticed pain anymore while serving tables.

This study does provide some valuable evidence towards MFR and MET as an effective

treatment for idiopathic scoliosis, however it does have several limitations. First, the therapist’s

inexperience with using a goniometer and performing the special tests could have skewed the

results and measurements. Second, the treatments were limited to the use of only MFR and MET.

While it is good to use limiting techniques to assess their effectiveness, using other modalities

and homecare could have been beneficial. Third, the ten-week protocol of the study. I think a

long term study would be very interesting to follow the changes and see if the results are

maintained. Lastly, the patient had recently sprained her right ankle before the treatment began

which could have altered her stance and affected her posture. She also had variable degrees of

stress with school which could have affected her mood and pain levels.


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In conclusion, there is some evidence that the use of MFR and MET can help treat the

dysfunctions that accompany idiopathic scoliosis. However, further studies are needed involving

a larger sample size, the use pre and post x-rays, and uniform protocol and assessment methods.

Idiopathic scoliosis is a complex disorder with many contributing factors and can affect each

individual differently over time. More long-term research needs to be done on the management

and progression of individuals with idiopathic scoliosis.

Conflict of Interest

It must be stated that there was a pre-existing relationship between the therapist and

patient prior to the commencement of this study. A therapeutic relationship was established at

the onset, avoiding possible biased and conflict of interest.

Acknowledgements

I would like to extend my sincerest gratitude to all of my instructors and classmates at

CDI College. Your encouragement throughout this program is much appreciated and you have

all contributed greatly to my education. I would also like to thank the participant for her time and

commitment throughout the case study.

.


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Appendix

Appendix 1. Appendix 2.

Pain Scale- Appendix 3.

1. Light touch

2. A little more pressure

3. Therapeutic pressure

4. Considerable amount of pressure, may have to breath through it.

5. Too much pressure and pain, stop


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Appendix 4.


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Appendix 5. Thoracic spine rotation

Appendix 6. Quadratus Lumborum Release


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Appendix 7. Distraction of SI Joints

Appendix 8. Posterior Rotation of the Innominate Bone


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Appendix 9. Central Torsion Manipulation

MET for Ribs- Appendix 10

1. Locate ribs you want to treat.

2. During exhalation follow the ribs until the patient can’t exhale anymore.

3. The patient then inhales while the practitioner resists inhalation.

4. Repeat 3-5 times.


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Appendix 11. X-rays taken February 2018

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